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1 <br />' WELL PERMIT APPLICATION FORM SITE <br /> / MITIGATION <br /> SAN JOAQUIN COUNT` PUBLIC HEALTH SERVICES MITI MITI <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> IV <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95292 <br /> r �Cu.S I (209) 458-3449 <br /> NON-REFUNnAESt.1;PERMITIRr=S I YF_AR FROM IDAic ISSUEQ <br /> AppriMbOn,s hereby made to San Jo--quirl County for a permit to construct andicr install the work described Ths applrca6as+fs made in asmoLanor with San <br /> J=agLnn County Develnpm©nt i 4tle,CTtaptar 9-1115 3 and the Standards of San Joaquin County Public Health Services,Ervlronmentai 1 iesiL`s Di�slan <br /> Assessors <br /> N1ELt Loc tlonZ�3j !,/.�[RGc� ,�o�lA Ctass Street � ter`_ C,iy S7y 'prr� Zip 9S'��S Parca[� fiG-/z7d-3(? <br /> Z �szxr Ptsana; /t'�� <br />' PROP�i TY Ownar_ 7A'-ry C.ST Tt�Gf��yEAddr2ss <br /> C-s7 Cantracfor_�3�ifi�4zr» "�'�.f� 4ttrlress 3 Fitrte.rr,� ecL, S•C., ricC1 t�c <br /> 5�7iIaL � Phone- - <br /> Lt�IG7 <br /> Ccnsutant I Sub Canbmctor /97r- . S �G%�a i�_Address -' CF�S$�� A City SPI✓ tGv 'F7 ir'LY7� <br /> GIS Coordlnabes-X_1/EL,7-. . y__2.7 S 77 95- Township 101 Range R (_ a; Section 3 bb <br /> WORK TO B FPERFORMED. <br />' $NEW WELLIBORING(CPT.GEOPROBE HYDROPLINCH,HAND-AUGERS GThER-) j']DES TRUCTION(ch=ose typc below) <br /> 13 SOIL SOQiNG ❑OVER-SORE <br /> a W^LL: ` �"1+✓!y, 2/ s , vAS-z r1�.4s- X II PR8&SUf2E GRat3T <br /> 'Other Grout Speeificatcerxs- <br /> COMMENTB iPO�Osc�? c.l�G [�`Glrf�iFr✓r rr �ti•15:1Z�1�p VA/ — r�iCO�Qs2Y. G/ I� GcG. <br /> T"PE OF WEU INSTALLATION-'TYP_ GONST'RUGrION SPEC1FtCA71O133 i <br /> q MON£i ORING g HOLLOW STEM ❑IA OF BOREHOLE /V Z-��MULTIPLE CASINGS?I YES C NO WELL CASING DIA 9l�Y <br /> �`;rL! tr <br />' III.EXTRACTION (]AIR HAMMF_R1DFZIVEN CASING 7HICKNESS 5ctt z10 'Y PE OF CASING 1 STEEL 1I FVC fj OTHF_R- - (" <br /> .11 VppQ{ ❑MUD ROTARYDFr-'}H OF Gr7CU7 SEAL 3�7 e2r; TREMIETYPE 7t7 BE tSSi"II 9 AUGERS jK HOS~ <br /> yl AIR SPARGP- {]PUSH POINT GROUT SEAL PUMPED A Yes ]3 No (NdTE- MAXIMUM FREE-FALL GI=P'i H IS n0') <br /> jI SOL HoRm HAND AUGER �ta1�S`� GROUT SPECIFICATIONS /F�,t�TON , �C/O.LC z#� - <br />' ❑OTHcR T O }-fER APPROX BORING DEr`i H Fr' £d 1` p BOL 1 cII TrRAFFIC SCX or 118ki OVi=PIPE <br /> CONDUCTOR CASING PR0PdSFD7 (if YES,list spocirGatforis here) <br /> -COMMENTS: Sir 77� G,��a �� v��� s �7 E©Z A/,EE7Z_, C0.7/sTfr�CIG;tJ c,rt��S <br />' NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS_ <br /> I hereby cern that I have prepared this application and diet the work will be done in accordance with, San Joaquin <br /> Gallrtty Ordln nc , Rs1les and R ons,anti all applicable California StateiiLaws J _ <br /> _ _ ZitleJCampany tST� G F5 C T(�S�U <br /> Fret NemsC�l�Gz�� � � <br /> DEPARTMENT USE ONLY D�:g <br /> SITE MAP IN UNIT IV FILE, ADDRESS- <br /> WORK FLAN 0XI ED: <br /> Apalicsttcn Acxpte�+8y <br /> Date 1ssaed <br /> ❑ate Fina( ?7atm <br /> Grout Inspection By Inspection By_ <br /> Destruc'+ar Inspector Sy Date <br /> tcoMMENTS 1 COSH NO MONS <br /> . ACCOUN T INC O3N y AIl3i� <br /> PE CODES F-IHFQ AMOUNT Railtitb C', ax� � Fac n SY ZkATE I piERMIT I SERVICE�DLfE57 T lI(3[flICE <br /> C-57 7VI-71� C•-57 LET-,e.- C;ALt7horiz='I1nn to sign per-mIT Enc:-=ch-nen1 dnc <br /> i <br />